HIGH-QUALITY CPR, IS THAT ALL YOU GOT: WHY TEAMWORK MATTERS Cory Miller RN, BSN, CCRN

ExpoED Class Codes: 5/23 EXED161 5/24 EXED161A

Overview and Learning Objectives Content

This session will explore the different human factors that affect team leadership behavior and performance of the resuscitation team. Training options and strategies for nurses and multidisciplinary healthcare team members to improve communication, team dynamics, role identification and task delegation will be discussed.

Learning Objectives This session will enable the attendee to: •  Identify 3 human factors shown to affect team performance during

cardiopulmonary resuscitation. •  Discuss 3 ways to enhance multidirectional communication among

team members during a cardiac resuscitation.

Survival from Cardiopulmonary Arrest…..

Growing interest in the effects of

human factors and team dynamics on the performance of resuscitation teams

Minimal improvement in

survival for in-hospital cardiac arrest over the last several decades

Survival outcomes vary widely among

institutions

We train individuals but

perform as a team

Edelson, DP, et al (2014). J Hosp Med, 9(6), 353-357.

Trajectories of a Code

Time

Cha

os

Time

Cha

os

Time

Cha

os

Time

Cha

os

“Good” or “Bad” Code? • Qualities of a “Bad” Resuscitation Event:

•  Chaos •  No defined leader •  Conflict among leaders or over leadership •  Confusing and/or inaccurate communication •  Deviation from standard guidelines •  Loud •  Crowded •  Safety issues

Mahramus, T., et al (2013) CNS, (27)6, 291-7.

Human Factors: Definition “All things that make us different from logical, completely predictable machines”

“How we think and relate to other people, equipment and the environment.”

“The things that affect our personal performance.”

Clinical Human Factors Group. www.chfg.org Accessed 5-12-16

Human Factors Affecting Code Teams

Leadership

•  Identification of leader • Communication •  Task Distribution • Situation Monitoring

Teamwork

•  Leadership • Communication •  Task Management • Mutual Performance

Monitoring

Anderson, P, et al. (2010). Resuscitation, 81(6), 703-11. Norris, E, et al. (2012). Resuscitation, 83(4), 423-7.

Leadership D

efin

ition

The ability to influence, motivate and enable others to contribute towards the common goals of the team

Trai

ning

Leadership skills can be taught

Pra

ctic

e Leadership training has sustained effect

Clinical Human Factors Group. www.chfg.org Accessed 5-12-16 Yeung, J., et al (2012). Crit Care Med, 40(9), 2617-21. Hunziker, S., et al (2010). Crit Care Med, 38(4), 1086-91. Marsch, S., et al (2004). Resuscitation, 60(1), 51-6.

Leadership and Teamwork on Outcomes S

urvi

val f

rom

IHC

A

Impacted by: •  Quality of CPR

•  Compression rate •  Compressions

depth •  Compression

fraction •  Time to

defibrillation •  Adherence to

guidelines

Effe

ct

Leadership and Teamwork have been shown to improve the quality of CPR and adherence to guidelines.

Out

com

es??

Proposed: Better Leadership and Teamwork will improve survival from IHCA

Hunziker, S. et al (2011), JACC, 57(24), 2381-8. Talikowska, M, et al (2015). Resuscitation, 96, 66-77. Yeung, J., et al (2012). Crit Care Med, 40(9), 2617-21.

Leadership: Team Leader

• Identification • Code Team Leader should be easily identified

• Visually: Sticker, badge, vest etc. • Verbally: Confident verbalization

Communication •  Definition: “Transmission of information between one person to

another person or group.”

•  Purpose: 1.  Build and uphold team structure 2.  Coordinate team processes 3.  Information gathering and exchange

•  Associated with: 1.  Treatment errors 2.  Overall CPR performance 3.  Algorithm adherence

Castelao, E, et al (2013). J Crit Care, 28(4), 504-21.

Communication Leadership

• Use of Closed-Loop Communication

• Use of short, clear statements (“Less is more”)

•  Think out loud • Give orders to a person •  Invite feedback and input

from the team

Teamwork

• Confirm receipt of orders • Confirm completion of

tasks • Voice critical findings “Call

Out” • Communicate specific

findings and avoid stating diagnosis

TeamSTEPPS™ www.ahrq.gov Accessed on 5-12-16

Task Completion During A Code

Leadership: Task Distribution

• Roles: •  Assign •  Assess •  Set expectations

• Avoid task information overload

• Remain Hands Off

Teamwork: Task Management

• Communicate task completion

• Assist each other • Coordinate within team

the distribution of tasks

Anderson, P, et al (2010). Resuscitation, 81(6), 695-702 Mahramus, T., et al (2013) CNS, (27)6, 291-7.

Monitoring of Code Leadership:

Situation Monitoring

• Maintain overview of situation

•  Identify, process and comprehend critical elements (patient, team, environment, progress)

• Avoid fixation on select details

• Perform periodic reviews of situation

Teamwork: Mutual Performance Monitoring

• Monitor each other’s performance “Have each other’s back” •  Task assistance •  Anticipate needs

•  Flexibility • Mutual respect

Anderson, P, et al (2010). Resuscitation, 81(6), 695-702 TeamSTEPPS™ www.ahrq.gov Accessed on 5-12-16 .

Barriers to Leadership and Teamwork • Hierarchies

•  Status characteristics performance expectations hierarchies

•  Creates barrier to sharing of information

• Stress Causes: •  Impaired memory •  Reduced concentration •  Difficulties in decision making

Muller, MP, et al (2009). Resuscitation, (80) 8, 919-24. Hunziker, S, et al (2011). JACC, 57(24), 2381-8.

Barriers to Leadership and Teamwork Conflict

Three Degrees: 1.  Discussion 2.  Disagreement 3.  Dispute

Response to Conflict: 1.  Acknowledge 2.  Assess value 3.  Add to plan

or 4  Assertive and take

action

Norris, E, et al (2012), Resuscitation, 83(4), 423-427.

Recommendations •  Leadership training for Code Team leader and Code Team

members •  Increases confidence •  Decreases stress •  Improves quality of leadership communication and overall

leadership skills

• Practice with inter-professional team •  With simulation

• Debrief after every code •  Entire group that participated in code •  Code Team

Code Blue Team Leader Tips Upon Arrival: • Announce arrival and receive handoff:

•  “I am the CCU resident and will be running this code.”

•  “Please confirm code status.”

•  “Who has been running the code and can give me a handoff?”

• Assess for high quality CPR and defibrillate if indicated

First 2 minutes: • Assigns/assesses roles and give expectations • Debride room • Ask for primary team to be contacted • Early interventions:

•  Assess patient •  Review or send labs •  Review medications •  Give volume (if appropriate) •  Review recent events and H&P

General Tips: 1.  Remain calm. 2.  Give orders to a person.

•  Get confirmation of order and completion.

3.  Ask for feedback from the room.

4.  To order drugs: “Give ______ now and Prepare ______ for the next cycle.”

5.  Think out loud.

6.  Periodically summarize the key information and situation.

Cardiopulmonary Arrest: The Perfect Storm • High Stakes • High Complexity • High Variability • High Stress •  Time Sensitive •  Low Frequency • Unplanned

Conclusion Improving the quality of team building and team dynamics are key factors for increasing the quality of the resuscitation and survival outcomes. AHA 2015 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: “…..The inclusion of team and leadership training as part of ACLS training is reasonable.” (Class IIa, LOE C-LD)

References: 1. Andersen PO, Jensen MK, Lippert A, Ostergaard D. Identifying non-technical skills and barriers for improvement of teamwork in cardiac arrest teams. Resuscitation. 2010;81(6):695-702. 2. Fernandez Castelao E, Russo SG, Riethmuller M, Boos M. Effects of team coordination during cardiopulmonary resuscitation: a systematic review of the literature. Journal of critical care. 2013;28(4):504-21. 3. Hunziker S, Buhlmann C, Tschan F, Balestra G, Legeret C, Schumacher C, et al. Brief leadership instructions improve cardiopulmonary resuscitation in a high-fidelity simulation: a randomized controlled trial. Critical care medicine. 2010;38(4):1086-91. 4. Hunziker S, Johansson AC, Tschan F, Semmer NK, Rock L, Howell MD, et al. Teamwork and leadership in cardiopulmonary resuscitation. Journal of the American College of Cardiology. 2011;57(24):2381-8. 5. Mahramus T, Frewin S, Penoyer DA, Sole ML. Perceptions of teamwork among code team members. Clinical nurse specialist CNS. 2013;27(6):291-7. 6. Norris EM, Lockey AS. Human factors in resuscitation teaching. Resuscitation. 2012;83(4):423-7. 7. Talikowska M, Tohira H, Finn J. Cardiopulmonary resuscitation quality and patient survival outcome in cardiac arrest: A systematic review and meta-analysis. Resuscitation. 2015;96:66-77. 8. Yeung JH, Ong GJ, Davies RP, Gao F, Perkins GD. Factors affecting team leadership skills and their relationship with quality of cardiopulmonary resuscitation. Critical care medicine. 2012;40(9):2617-21.

THANK YOU! Cory Miller RN, BSN, CCRN Cory.miller3@att.net ExpoED Class Codes: 5/23 EXED161 5/24 EXED161A